Pathways to Work: health or wealth – where does true value lie?
Written By Theodore Spaliviero-Shaw
How we prescribe value to each individual, equitably, is a decision. It reflects both the principles and wellbeing of a society. Through equitable recognition of the enduring value of the individual, we strengthen a shared sense of community and purpose, resisting the lure of utilitarianism, whereby we regress to the famous ‘Trolley Problem’ and determine that sacrifice of the minority is the moral and just thing to do.
On 18 March, the Department of Work and Pensions published its Pathways to Work green paper, detailing the government’s vision for a more successful and sustainable benefits system. Coming in at 109 pages, it is not a recommendation for a bit of light reading.
Nor, interestingly, is it a policy paper of consultation. Rather, it is a clear policy paper of intent to shift how government considers the relationship between disability, health and work.
How?
Well first, we must understand the current system in place and the people it serves. Second, the actual changes being introduced, looking at both their implementation and their conformational effect on the structure of the benefits system. Then finally, the consequences – what will this mean on an individual and societal level?
The current system
The benefits system is a somewhat devolved issue. Even though most of the welfare reforms will affect the whole of the UK, some aspects will only be explicitly for England and Wales – this article is written with that understanding.
The current system of health and disability benefits mainly comprises of four schemes that interrelate and function semi-complementarily to one another. These are as follows:
Personal Independence Payment (PIP) is a widely used, non-means tested financial support benefit with its own discrete assessment for long-term disability and health conditions, in terms of both daily living and mobility.
Employment and Support Allowance (ESA) is a form of non-means tested, financial support awarded to those who lose their job, based on a health and disability assessment. It requires active job seeking to maintain the award.
Disability Living Allowance (DLA), a remnant of a 1992 policy of the last Conservative government, is a non-contributory, non-means tested, and tax-free benefit for children currently under the age of 16 and those who were 65+ in 2013 when PIP was introduced.
Then finally, Universal Credit (UC) is a widely used, means-tested financial support benefit for those on low income or out of work. Specifically in this article, both the standard allowance and health element of UC will be discussed. The health element is a significant financial measure in addition to the standard allowance and is assessed by the ability of an individual to work due to a health condition or disability. Depending on how an individual is categorised, they are entitled to greater additional financial support and decreased requirement to pursue employment.
This is the system currently. Now, how is this going to change?
The changes – a paradigm shift.
To understand the changes being introduced in the proposed reforms, we must divide them into three areas. Firstly, how financial support will be assessed in the future. Secondly, how financial support on offer will change. Then finally, what new proposals will be introduced.
So, starting as we mean to continue, what is the take, and what is the give?
1. Assessments – streamlining, refining, excluding?
The principal target of assessment reform will be PIP, having a cooperative effect on the UC health element. The current policy proposes to uncouple the UC health element from the ability of an individual to work. Instead, PIP will act as a one-size-fits-all assessment, with health professionals assessing individuals on a stricter points system assessing both daily living and mobility. Only individuals with sufficiently high points for the daily living assessment will then be eligible for the UC health element (a choice that will exclude individuals with mobility issues).
These reforms will end both the reductive categorisation of individuals based on their supposed utility as a worker as well as reducing the complexity of accessing support, streamlining and simplifying the assessment process.
The shortfall? Stringent assessment criteria that will exclude a greater proportion from the most generous benefit support, including proposals to deny this support to those under 22. More on this later.
Why? The government projects that the number of working-age adults on PIP is set to double by 2030, a rise of £12.3 billion in the next five years, and those on the UC health element to increase by the “entire population of Birmingham” over the next decade.
Hence the solution: make access to this support harder. In the same way that you can decrease flow through a pipe by narrowing its radius. (As I had fun discovering when my sink stopped draining, requiring me to try to unclog it with a plunger. Life lesson, don’t empty oil down the sink. But I digress.)
2. Financial support – cutting down from the top, bumping up from below.
Perhaps most tangibly significant of the reforms proposed are the cuts.
Axing the top of the pyramid, the UC health element (the support for those on UC with a health condition that restricts their ability to work) will see a slash in its generosity from £97 to £50 per week for new claimants from this time next year (2026). This will be tepidly offset by a £7 rise in the UC standard allowance but still represent a net £40 drop in weekly financial support, if on both schemes. Even with this increase to £98 per week, the UC standard allowance will still be below the £120 needed for a single adult a week, as shown in research by the Joseph Rowntree Foundation. The rawest reflection of the government’s desire to drive a ‘pro-growth’ agenda, this significant disincentivisation of the highest forms of financial support, alongside a more restrictive assessment criteria, will contribute to the slowing of the rate of increase in government expenditure. Helping balance the books but bringing into disrepute a supposed government policy of “hospital to community” by leaving more individuals in the community without the support they need.
As part of the agenda for the to-be-published 10 Year Plan for the NHS, the strategic shift of “hospital to community” aims to establish new “neighbourhood health services” whereby sub-regional NHS bodies and local authorities jointly plan primary and community care for their local populations. The vision? Integrating services and delivering equitable and patient-centred care built around local communities. However, this is still in the embryonic stage, limited to case-studies (links in the QR code). Thus, it is under threat of being directly undermined by leaving individuals less able to support themselves financially, continuing health inequalities and increasing what will be a great strain on this evolution in healthcare delivery.
Furthermore, the Department of Work and Pensions is exploring whether to increase the age at which individuals go from DLA to PIP from 16 to 18, limiting the access of young people to the more expansive support offered under PIP, in line with a general approach to discourage young people from accessing benefits support.
3. New proposals – can small actions go a long way?
However, it is not just take – there are a few breadcrumbs of give.
To enable a more ‘pro-work’ benefits system, the Department of Work and Pensions will neatly follow the title of its own green paper. It will create Pathways to Work and bump up funding for primary care, inspired by “hospital to community” NHS reform.
Employment and Support Allowance (ESA) will morph into the newly proposed Unemployment Insurance (UI). Independent of a health assessment and absorbing other unemployment support on offer, it is looking to be set at the same rate as ESA is currently, £138 per week. Through simplifying between-employment support, it is hoped this will increase its accessibility and evolve the benefits system to act more as a stopgap than a long term solution for a greater proportion of those using it. Working off the probability that people are more likely to return to employment in the short period after losing their job, as published by the Office for National Statistics (ONS), and through finding employment avoid the need to use the benefits system long-term.
Employment reform has been a key area of policy since the start of this parliament. Through the enactment of the Make Work Pay plan, workers’ rights are to be strengthened, relevantly with statutory sick pay and flexible working, alongside raising the national living wage. Additionally, the Get Britain Working plan intends to overhaul Jobcentres and introduce the community-based Youth Guarantee focusing on maintaining young people in employment and training rather than on benefits support.
“So what?”, I hear you say. “Why does this matter? Am I not reading RUMS Review, not the Employment Review!?” Sigh, yes! Read on!
Why? Prevention over treatment.
Entering into 2025, there are now nearly 1 million 16-24 year olds who are Not in Education, Employment, or Training (NEET). This represents fewer than one in eight young people. Within the last two years alone, individuals classified as NEET have risen by nearly 250,000, with the same number currently citing long-term or temporary sickness as the principal reason. Simultaneously, there has been an increase of 800,000 people not in work since the pandemic, centrally due to ill health.
Thus, the perceived solution is to preventatively support youth and the working-age population into employment. Alongside the Youth Guarantee, there is a general commitment of £1 billion a year for employment, health and skills to support working-age adults on out of work benefits by the end of the decade back into employment.
The goal? A “more active system” of integrated pathways to work, informed by the 2010 Marmot Review that good and fair employment is a key factor in social determinants of health.
Finally (congrats for getting this far, it is quite difficult to make a policy paper engaging to read), combined with this, there is a not-so-novel recognition by the Department of Health and Social Care (DHSC) of a need for care to shift from “hospital to community” in this green paper. There will be a £889 million package for general practices over the next two years with sub-regional level expenditure on mental health services maintained, acknowledging the continued, crushing weight of need for community-based services. Echoing the sentiment again of the Marmot Review.
Through increasing the capital for the Social Care Grant and Carers Allowance, concurrent with a £172 million uplift to the Disabled Facilities Grant over the next two years, the government is attempting to maintain a moral argument of supporting individuals at a community level, whilst bending themselves to fit fiscal rules, as recommended in the Darzi Report (2024) to bring “care closer to the home”.
The discussion – have we truly appreciated the complexity of integrated community care?
It was Mark Twain who said, “history doesn’t repeat itself, but it often rhymes”.
I am inclined to agree with him.
Whether the wonderful experiment of the NHS and the welfare state is a poetic expression of compassion for the individual perhaps falls outside the purview of this article (and this discipline – though write to me and maybe I can have a shot at it). However, what is not is the broken record repeating various iterations of the need for NHS and social care reform, which is both unhealthy in terms of devaluing policy proposals and toxic to political discourse by polarising the relationship between ourselves and our government serving us.
Successive governments have ceded a legacy of sweeping statements, from “liberating the NHS” (2010); “(to) fix the crisis in social care once and for all” (2019); and now to “fixing the foundations” (2024). Each brings forward waves of reforms centred on reorganisation of management and gradual expenditure increases. Each, however, have failed to execute effective integrated community care. Now, as the prevalence of long-term health conditions needing to be managed in the community increases, having risen within working-age adults to 36% compared to 29% a decade ago - is it such a surprise that the demand for benefits support has increased?
However, more than this, the shameless continuation of the legacy of variations of austerity by successive governments, which arguably had authentic intentions of increasing the efficiency of the state and empowering the individual - has failed. As found in the Marmot Review 10 Years On, combined with the significant impact of the pandemic, austerity has driven up health inequality and child poverty in society. If anything, this has increased the urgency for significant investment into the community, not cuts.
Yet, in reading this policy paper two key things become apparent. It remains clouded by incessant short term economic priorities and misunderstands the role of prevention and community care.
The number of primary legislation proposals in the government’s Pathways to Work, unusual for a green paper, reflects government need to find savings to include in the Spring Statement to keep within Rachel Reeves’ fiscal rules. In light of the significant overshoot in borrowing costs in February, the projected £5 billion in savings from cuts in this green paper may more notably reflect economic constraints and pressures than authentic social care policy.
Whilst there is both evidence and merit in primary prevention through employment, this cannot be in isolation. Redirecting money from disability and health benefits to employment support reflects the zero-sum thinking that is endemic in government. According to The Kings Fund, one in seven adults faces lifetime care costs of over £100,000, brought on by approaches like this to healthcare policy. This leaves many to save for care rather than a legacy, contributing to wealth inequality at an individual level and hindering long-term planning at an institutional level. Whilst longsight may be rediscovered by big policy like the “neighbourhood health service”, in combination with benefit cuts we may risk a shy return to old fashioned paternalism by the weakening of the agency of the individual.
Conclusion - a tennis analogy.
Is there a need for reform? Certainly, the current benefits system is unsustainable.
However, will these decisions lead to a just benefits system? This is yet to be seen. Without significant and systemic ambition in the upcoming 10 Year Plan to provide a real pathway to sustainable integrated community care, it is hard to see a way through.
So, as a non-tennis player using a tennis analogy…
The ball is in Wes Streeting’s court. How he chooses to swing will determine whether we call “Match point!” or “Out of bounds”.
Read the rest of the edition here